Provider Demographics
NPI:1780042366
Name:CEDAR VALLEY MEDICAL SPECIALISTS, PC
Entity type:Organization
Organization Name:CEDAR VALLEY MEDICAL SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GILMORE
Authorized Official - Middle Name:
Authorized Official - Last Name:IREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-235-5390
Mailing Address - Street 1:PO BOX 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4006 JOHNATHAN ST
Practice Address - Street 2:STE B
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-9395
Practice Address - Country:US
Practice Address - Phone:319-233-0222
Practice Address - Fax:319-287-8094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1497794242Medicaid
IA1497794242Medicaid